A survey of barriers and facilitators to the adoption of buprenorphine prescribing after implementation of a New Jersey-wide incentivized DATA-2000 waiver training program.

BACKGROUND: Opioid-involved overdose deaths continue to rise in the US, despite availability of highly effective treatments for opioid use disorder (OUD), in part due to the insufficient number of treatment providers. Barriers include the need for providers to gain expertise and confidence in providing MOUD to their patients who need these treatments. To mitigate this barrier, New Jersey sponsored a buprenorphine training program with financial incentives for participation, which met the then existing requirement for the DATA-2000 waiver. In a 2019 follow-up survey, participants reported on barriers and facilitators to subsequent buprenorphine prescribing. METHODS: Participants in the training program completed a 10-min electronic survey distributed via email. The survey addressed demographics, practice characteristics, current buprenorphine prescribing, and barriers and facilitators to adoption and/or scale up of buprenorphine prescribing. RESULTS: Of the 440 attendees with a valid email address, 91 individuals completed the survey for a response rate of 20.6%. Of the 91 respondents, 89 were eligible prescribers and included in the final analysis. Respondents were predominantly female (n = 55, 59.6%) and physicians (n = 55, 61.8%); representing a broad range of specialties and practice sites. 65 (73%) of respondents completed the training and DEA-registration, but only 31 (34.8%) were actively prescribing buprenorphine. The most frequently cited barriers to buprenorphine prescribing were lack of access to support services such as specialists in addiction, behavioral health services, and psychiatry. The most frequently reported potential facilitators were integrated systems with direct access to addiction specialists and psychosocial services, easier referral to behavioral health services, more institutional support, and improved guidance on clinical practice standards for OUD treatment. CONCLUSION: More than half (52.3%) of those who completed incentivized training and DEA registration failed to actively prescribe buprenorphine. Results highlight provider perceptions of inadequate availability of support for the complex needs of patients with OUD and suggest that broader adoption of buprenorphine prescribing will require scaling up support to clinicians, including increased availability of specialized addiction and mental health services.

Drug and Alcohol Use in Trauma Patients Before and During the COVID-19 Pandemic.

INTRODUCTION: Since the implementation of national stay-at-home orders during the COVID-19 pandemic, there has been rising concerns regarding prolonged social isolation that many individuals face. Given the link between increased stress and alcohol and drug use, our study investigated admission trends and patterns of alcohol and drug use in trauma patients. METHODS: This was a single center, retrospective cohort study comparing trauma patients admitted before the pandemic and during the first wave. We compared patient demographics, injury characteristics, and outcomes of substance screen negative, positive, and unscreened patients admitted. Patients screened positive if they had a positive urine drug screen (UDS) and/or a blood alcohol concentration (BAC) ≥10 mg/dL. RESULTS: There were 3906 trauma admissions in the year prior to and 3469 patients in the first year of the pandemic. No significant demographic differences were presented across time periods. Rates of UDS and BAC screening remained consistent. Equivalent rates of alcohol and drug positivity occurred (34% versus 33%, 17% versus 18%, P = 0.49). The total prevalence of alcohol use disorders (4% versus 5%, P < 0.001) and psychiatric disorders (6% versus 7%, P = 0.02) increased during the pandemic. CONCLUSIONS: The prevalence of diagnosed alcohol use and psychiatric disorders in trauma patients increased during the COVID-19 pandemic while rates of acute alcohol and drug screen positivity remained the same. These observations suggest a possible link between pandemic stressors and exacerbation of alcohol use and psychiatric conditions in trauma patients. During a changing pandemic landscape, it remains pertinent to increased screening for these conditions regardless of substance screen positivity upon admission.

Satisfaction with group-based appointments among patients with opioid use disorder in an urban buprenorphine clinic.

Background: Successful implementation of group-based appointments can increase capacity to treat patients, reduce costs, and improve productivity. We sought to understand the acceptability of group-based appointments for opioid use disorder (OUD) in an urban clinical setting that treats predominantly ethnic minority populations. Methods: A survey collecting data on demographics, substance use, co-morbid psychiatric conditions, and satisfaction with group-based opioid treatment (GBOT) was conducted among patients 18 years and older with OUD attending an urban buprenorphine clinic between December 2019 and February 2020. Results: Thirty-nine patient surveys were completed. Among participants, 64.1% identified as Black/African American and 76.9% identified as male. The mean age was 51.2 years. Participants reported overall high levels of satisfaction with group-based appointments though GBOT was not strongly preferred over individual visits. On a 5-point Likert scale, 69.2% of participants agreed or strongly agreed that their medical needs were met during group-based appointments. A majority of participants agreed or strongly agreed that medical information received from the clinical team (97.4%) and other patients (82.1%) were valuable. Most participants (82.1%) reported adherence to treatment plans became easier since attending GBOT. Age and self-identified employment status as disabled or retired were positively associated with total satisfaction scores. Conclusions: Patients in a predominantly Black/African American and Hispanic/Latinx community with co-occurring mental health disorders and other substance use reported overall satisfaction with GBOT and would recommend this modality to other patients.

DATA 2000 waiver training for medical students: Lessons learned from a medical school experience.

BACKGROUND: In the midst of this national opioid crisis, it has become apparent that there is a large shortage in the workforce of treatment providers equipped to deliver evidence-based care for opioid use disorders (OUD). Medications for opioid use disorder (MOUD), such as buprenorphine, are crucial in reducing mortality in those with OUD, and yet prescribers must meet federal waiver requirements under the Drug Addiction Treatment Act of 2000 (DATA 2000). There are now several pathways for medical schools to satisfy these waiver requirements for all graduates, but this has not yet become widespread. We propose that including a DATA 2000 waiver training within the medical school curriculum is a feasible and effective way to meet eligibility requirements to prescribe buprenorphine. Methods: As part of a longitudinal opioid curriculum requirement, we implemented a DATA 2000 waiver training for all rising Year 4 medical students. One hundred sixty-nine students completed a hybrid (online and in-person) waiver training. The majority completed a pre- and post-survey. Results: The pre-training survey showed 93% of rising Year 4 medical students (112/120) reported participation in care of patients with OUD. Students six month post-training reported a rise in confidence (1.94 to 2.45; p < 0.01) and knowledge (2.27 to 2.76; p < 0.01) regarding MOUD. They also reported their plans to apply for the buprenorphine waiver once licensed and reported being more likely to prescribe buprenorphine for OUD as a result of the training (mean = 3.35; SD = 1.36; 0 = extremely unlikely to 5 = extremely likely). Conclusions: We successfully implemented a DATA 2000 waiver training as a mandatory requirement for the medical school curriculum. Further studies are needed to determine optimal timing, best format, and frequency of reinforcement of MOUD educational content across the undergraduate and graduate medical education continuum.

Changes in psychiatry residents' attitudes towards individuals with substance use disorders over the course of residency training.

BACKGROUND AND OBJECTIVES: Psychiatry residents provide care for individuals diagnosed with co-occurring mental illness and substance use disorders (SUDs). Small studies have shown that clinicians in general possess negative attitudes towards these dually diagnosed individuals. This is a serious concern, as clinicians' stigmatizing attitudes towards individuals with mental illnesses may have a particularly potent adverse impact on treatment. The goal of this study was to examine the attitudes of psychiatry residents towards individuals with diagnoses of schizophrenia, multiple SUDs, co-occurring schizophrenia and SUDs, and major depressive disorder. METHODS: A questionnaire was sent to psychiatry residents (N = 159) around the country. It was comprised of two sections: (i) demographic information, which included information about level of training; and (ii) the 11-item Medical Condition Regard Scale (MCRS) for individuals with the four different diagnoses. RESULTS: Psychiatry residents had more stigmatizing attitudes towards individuals with diagnoses of SUDs with and without schizophrenia than towards those individuals with diagnoses of schizophrenia or major depressive disorder alone. Senior residents possessed more negative attitudes towards individuals with SUDs than junior residents. DISCUSSION AND CONCLUSIONS: The attitudes of psychiatry residents' towards individuals with SUDs with and without schizophrenia were negative and were worse among senior residents. There were many potential reasons for these findings, including repeat negative experiences in providing care for these individuals. SCIENTIFIC SIGNIFICANCE: The negative attitudes of psychiatry residents towards individuals with SUDs are worrisome. Future work is needed to better understand these attitudes and to develop interventions to improve them. (Am J Addict 2017;26:75-79).

Intensive ketamine use for multiple years: A case report.

Ketamine is known within the medical field for its anesthetic properties, yet its unique psychedelic and antidepressant properties are being increasingly recognized. We document the case of a patient with bipolar I disorder and an extensive history of substance dependence who used large doses of ketamine (1-3 g) on a daily basis over a period of 5 years, and described acute antidepressant effects as well as diminished cravings for alcohol. While his use was untenable and ultimately led to an inpatient admission, it is notable that he did not experience a withdrawal syndrome nor did he have any observable cognitive deficits upon cessation of use. Such a unique drug profile suggests that further exploration of its risks and therapeutic potential in treating mood and addiction disorders is warranted.

The role of recovery peer navigators in retention in outpatient buprenorphine treatment: a retrospective cohort study.

BACKGROUND: Racial and ethnic disparities are evident in the accessibility of treatment for opioid use disorder (OUD). Even when medications for OUD (MOUD) are accessible, racially and ethnically minoritized groups have higher attrition rates from treatment. Existing literature has primarily identified the specific racial and ethnic groups affected by these disparities, but has not thoroughly examined interventions to address this gap. Recovery peer navigators (RPNs) have been shown to improve access and overall retention on MOUD. PATIENTS AND METHODS: In this retrospective cohort study, we evaluate the role of RPNs on patient retention in clinical care at an outpatient program in a racially and ethnically diverse urban community. Charts were reviewed of new patients seen from January 1, 2019 through December 31, 2019. Sociodemographic and clinical visit data, including which providers and services were utilized, were collected, and the primary outcome of interest was continuous retention in care. Bivariate analysis was done to test for statistically significant associations between variables by racial/ethnic group and continuous retention in care using Student's t-test or Pearson's chi-square test. Variables with p value ≤0.10 were included in a multivariable regression model. RESULTS: A total of 131 new patients were included in the study. RPNs improved continuous retention in all-group analysis (27.6% pre-RPN compared to 80.2% post-RPN). Improvements in continuous retention were observed in all racial/ethnic subgroups but were statistically significant in the non-Hispanic Black (NHB) group (p < 0.001). Among NHB, increases in continuous retention were observed post-RPN in patients with male sex (p < 0.001), public health insurance (p < 0.001), additional substance use (p < 0.001), medical comorbidities (p < 0.001), psychiatric comorbidities (p = 0.001), and unstable housing (p = 0.005). Multivariate logistic regression demonstrated that patients who lacked insurance had lower odds of continuous retention compared to patients with public insurance (aOR = 0.17, 95% CI 0.039-0.70, p = 0.015). CONCLUSIONS: RPNs can improve clinical retention for patients with OUD, particularly for individuals experiencing several sociodemographic and clinical factors that are typically correlated with discontinuation of care.

Recovery peer navigators improve continuous clinical retention following initiation of outpatient treatment for opioid use disorder.Recovery peer navigators may be especially beneficial for patients with factors and identifiers commonly associated with discontinuation of care.

Improving Psychiatry Residents' Attitudes Toward Individuals Diagnosed with Substance Use Disorders.

Special attention needs to be paid to the attitudes of psychiatry residents toward individuals diagnosed with substance use disorders. The attitudes of trainees may be worse toward these individuals than toward individuals with other diagnoses, and these attitudes may worsen over time. While psychiatry residencies are increasingly teaching residents about how to diagnosis and treat individuals diagnosed with substance use disorders, more attention needs to be paid to educating residents about common attitudes toward these individuals. We recommend that psychiatry residency programs start with basic educational didactics and reflection exercises on attitudes toward individuals diagnosed with substance use disorders and that programs try to form a positive "hidden curriculum" in their institutions.

Transference-focused psychotherapy in the general psychiatry residency: a useful and applicable model for residents in acute clinical settings.

Transference-focused psychotherapy (TFP) is a manualized, psychodynamic treatment for severe personality disorders. Training in TFP during residency can provide a readily applicable model for understanding and treating personality pathology in a variety of settings, even for residents who do not obtain additional training in psychodynamic treatments or go on to practice psychotherapy. Although TFP was developed as a long-term outpatient treatment, the authors have found the diagnostic and theoretical framework and the clinical techniques described in the TFP treatment manual to be useful in acute settings, even when the clinician does not have a clearly established relationship with the patient. In the authors' experience, residents find this model of understanding and working with patients with personality disorders enjoyable to learn and easy to apply.